Hypotension, hypothermia, and vasoconstriction may alter pulse oximetry values by reducing arterial blood flow. Likewise, movement of the finger to which the oximeter is applied may interfere with interpretation of SaO2. All of these conditions limit the usefulness of pulse oximetry. Fever, tachypnea, and tachycardia don’t affect pulse oximetry values directly.

Question 2

A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:

A

hyperglycemia and glycosuria.

B

acute adrenocortical insufficiency.

C

restlessness and seizures

D

GI bleeding.

Question 2 Explanation:

Administration of a corticosteroid such as prednisone suppresses the body’s natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.

Question 3

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86% and he’s still wheezing. The nurse should plan to administer:

A

propranolol (Inderal)

B

albuterol (Proventil).

C

alprazolam (Xanax).

D

morphine

Question 3 Explanation:

The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client’s greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It’s given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client’s breathing. Propranolol is contraindicated in a client who’s wheezing because it’s a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

Question 4

Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

A

It decreases use of accessory breathing muscles

B

It helps prevent early airway collapse

C

It increases inspiratory muscle strength

D

It prolongs the inspiratory phase of respiration

Question 4 Explanation:

Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

Question 5

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

A

Enforcing absolute bed rest

B

Enforcing absolute bed rest

C

Restricting fluid intake to 1,000 ml/day

D

Enforcing absolute bed rest

Question 5 Explanation:

Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client’s ability to maintain a patent airway, causing a high risk of infection from pooled secretions

Question 6

Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review?

A

Prior outcomes of weaning

B

Fluid intake for the last 24 hours

C

Electrocardiogram (ECG) results

D

Baseline arterial blood gas (ABG) levels

Question 6 Explanation:

Before weaning a client from mechanical ventilation, it’s most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.

Question 7

Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

A

Semiconsciousness

B

Hypoxia

C

Delirium

D

Hyperventilation

Question 7 Explanation:

depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

Question 8

The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

A

helping him communicate

B

keeping his airway patent

C

preventing him from developing an infection

D

encouraging him to perform activities of daily living

Question 8 Explanation:

Maintaining a patent airway is the most basic and critical human need. All other interventions are important to the client’s well-being but not as important as having sufficient oxygen to breathe.

Question 9

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg?

A

Administer prescribed supplemental oxygen.

B

Administer a prescribed decongestant

C

Offer the client fluids frequently

D

Instruct the client to breathe into a paper bag

Question 9 Explanation:

The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options — such as administering a decongestant, offering fluids frequently, and administering supplemental oxygen — wouldn’t raise the lowered PaCO2 level

Question 10

Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

A

Heart rate of 100 beats/minute

B

Dilated and reactive pupils

C

Urine output of 40 ml/hour

D

Respiratory rate of 22 breaths/minute

Question 10 Explanation:

In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn’t affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler’s position and shouldn’t receive sedatives or other drugs that may further depress the respiratory center.

Question 12

A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

A

Immediately before a meal

B

When bronchospasms occur

C

When secretions have mobilized

D

At least 2 hours after a meal

Question 12 Explanation:

The nurse should perform chest physiotherapy at least 2 hours after a meal to reduce the risk of vomiting and aspiration. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn’t available) are a contraindication for postural drainage, another component of chest physiotherapy.

Question 13

A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:

A

earlobes

B

mucous membranes

C

lips

D

nail beds.

Question 13 Explanation:

Skin color doesn’t affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they’re affected by skin color

Question 14

A male client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that:

A

vancomycin should be administered rapidly in a large volume of fluid.

B

vancomycin should be infused over 60 to 90 minutes in a large volume of fluid.

C

vancomycin may cause irreversible neutropenia.

D

vancomycin should be administered over 1 to 2 minutes as an I.V. bolus.

Question 14 Explanation:

To avoid a hypotensive reaction from rapid I.V. administration, the nurse should infuse vancomycin slowly, over 60 to 90 minutes, in a large volume of fluid. Although neutropenia may occur in approximately 5% to 10% of clients receiving vancomycin, this adverse effect reverses rapidly when the drug is discontinued.

Question 15

A female client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

A

5 to 20 minutes.

B

5 to 60 seconds.

C

45 to 60 minutes.

D

30 to 40 minutes.

Question 15 Explanation:

Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, and then gradually lengthen this interval according to the client’s respiratory status. A client who doesn’t require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn’t be long enough to reveal the client’s true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

Question 16

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

A

Simple mask

B

Nasal cannula

C

Face tent

D

Non-rebreather mask

Question 16 Explanation:

A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent and nasal cannula — deliver lower levels of FIO2.

A male client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He’s placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

A

0.21

B

0.7

C

0.5

D

0.35

Question 18 Explanation:

An FO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air F IO 2 0.18 to 0.21.

Question 19

Nurse Julia is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which of the following interventions will most likely lower the client’s arterial blood oxygen saturation?

A

Encouragement of coughing

B

Incentive spirometry

C

Endotracheal suctioning

D

Use of cooling blanket

Question 19 Explanation:

Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improves oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn’t be affected

Question 20

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client’s medical history. Which condition is a predisposing factor for respiratory alkalosis?

A

Myasthenia gravis

B

Extreme anxiety

C

Narcotic overdose

D

Type 1 diabetes mellitus

Question 20 Explanation:

Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, and injury to the brain’s respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes mellitus may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul’s respirations) don’t cause excessive CO2 loss. Myasthenia gravis and narcotic overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

Question 21

A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

A

Impaired gas exchange related to airflow obstruction

B

Anxiety related to actual threat to health status

C

Activity intolerance related to fatigue

D

Risk for infection related to retained secretions

Question 21 Explanation:

A patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis. The other options also may apply to this client but are less important

Question 22

A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza?

A

Pulmonary edema

B

Pneumonia

C

Septicemia

D

Meningitis

Question 22 Explanation:

Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye’s syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren’t associated with influenza.

Question 23

What is the normal pH range for arterial blood?

A

7.35 to 7.45

B

7.55 to 7.65

C

7.50 to 7.60

D

7 to 7.49

Question 23 Explanation:

A pH less than 7.35 is indicative of acidosis; a pH above 7.45 indicates alkalosis.

Question 24

The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?

A

Apply an occlusive dressing and notify the physician.

B

Secure the chest tube with tape.

C

Place the end of the chest tube in a container of sterile saline.

D

Clamp the chest tube immediately.

Question 24 Explanation:

If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn’t clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.

Question 25

The amount of air inspired and expired with each breath is called:

A

residual volume.

B

tidal volume

C

vital capacity

D

dead-space volume

Question 25 Explanation:

Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways

Question 26

For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?

A

Measuring and documenting the drainage in the collection chamber

B

Keeping the collection chamber at chest level

C

Stripping the chest tube every hour

D

Maintaining continuous bubbling in the water-seal chamber

Question 26 Explanation:

The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse should not strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

Question 27

Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?

A

A positive reaction indicates that the client has been exposed to the disease.

B

The PPD can be read within 12 hours after the injection

C

A negative reaction always excludes the diagnosis of TB

D

A positive reaction indicates that the client has active tuberculosis (TB).

Question 27 Explanation:

A positive reaction means the client has been exposed to TB; it isn’t conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn’t exclude the presence of active disease

Question 28

A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

A

Partial pressure of arterial oxygen (PaO2)

B

Partial pressure of arterial carbon dioxide (PaCO2)

C

pH

D

Bicarbonate (HCO3–)

Question 28 Explanation:

The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client’s ventilation status, not oxygenation.

Question 29

A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client’s serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

Nurse Eve formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include:

A

eating a high-protein snack at bedtime

B

drinking more than 1,500 ml of fluid daily.

C

being overweight

D

eating more than three large meals a day.

Question 30 Explanation:

Conditions that increase oxygen demands include obesity, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals a day may cause fullness, making breathing uncomfortable and difficult; however, it doesn’t increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six a day).

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NCLEX Practice Exam for Respiratory System 1 (EM)

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Question 1

A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:

A

mucous membranes

B

earlobes

C

nail beds.

D

lips

Question 1 Explanation:

Skin color doesn’t affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they’re affected by skin color

Question 2

What is the normal pH range for arterial blood?

A

7.50 to 7.60

B

7.35 to 7.45

C

7 to 7.49

D

7.55 to 7.65

Question 2 Explanation:

A pH less than 7.35 is indicative of acidosis; a pH above 7.45 indicates alkalosis.

Question 3

Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review?

A

Fluid intake for the last 24 hours

B

Prior outcomes of weaning

C

Electrocardiogram (ECG) results

D

Baseline arterial blood gas (ABG) levels

Question 3 Explanation:

Before weaning a client from mechanical ventilation, it’s most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.

Question 4

A female client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

A

5 to 60 seconds.

B

30 to 40 minutes.

C

45 to 60 minutes.

D

5 to 20 minutes.

Question 4 Explanation:

Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, and then gradually lengthen this interval according to the client’s respiratory status. A client who doesn’t require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn’t be long enough to reveal the client’s true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn’t affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler’s position and shouldn’t receive sedatives or other drugs that may further depress the respiratory center.

Question 6

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg?

A

Instruct the client to breathe into a paper bag

B

Administer prescribed supplemental oxygen.

C

Administer a prescribed decongestant

D

Offer the client fluids frequently

Question 6 Explanation:

The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options — such as administering a decongestant, offering fluids frequently, and administering supplemental oxygen — wouldn’t raise the lowered PaCO2 level

Question 7

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

A

Face tent

B

Non-rebreather mask

C

Nasal cannula

D

Simple mask

Question 7 Explanation:

A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent and nasal cannula — deliver lower levels of FIO2.

Question 8

The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

A

preventing him from developing an infection

B

keeping his airway patent

C

encouraging him to perform activities of daily living

D

helping him communicate

Question 8 Explanation:

Maintaining a patent airway is the most basic and critical human need. All other interventions are important to the client’s well-being but not as important as having sufficient oxygen to breathe.

Question 9

The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?

A

Secure the chest tube with tape.

B

Clamp the chest tube immediately.

C

Apply an occlusive dressing and notify the physician.

D

Place the end of the chest tube in a container of sterile saline.

Question 9 Explanation:

If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn’t clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.

Question 10

Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

A

It prolongs the inspiratory phase of respiration

B

It decreases use of accessory breathing muscles

C

It helps prevent early airway collapse

D

It increases inspiratory muscle strength

Question 10 Explanation:

Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

Question 11

A male client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that:

A

vancomycin may cause irreversible neutropenia.

B

vancomycin should be infused over 60 to 90 minutes in a large volume of fluid.

C

vancomycin should be administered rapidly in a large volume of fluid.

D

vancomycin should be administered over 1 to 2 minutes as an I.V. bolus.

Question 11 Explanation:

To avoid a hypotensive reaction from rapid I.V. administration, the nurse should infuse vancomycin slowly, over 60 to 90 minutes, in a large volume of fluid. Although neutropenia may occur in approximately 5% to 10% of clients receiving vancomycin, this adverse effect reverses rapidly when the drug is discontinued.

Question 12

Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?

A

A positive reaction indicates that the client has active tuberculosis (TB).

B

A negative reaction always excludes the diagnosis of TB

C

The PPD can be read within 12 hours after the injection

D

A positive reaction indicates that the client has been exposed to the disease.

Question 12 Explanation:

A positive reaction means the client has been exposed to TB; it isn’t conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn’t exclude the presence of active disease

Question 13

Nurse Julia is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which of the following interventions will most likely lower the client’s arterial blood oxygen saturation?

A

Endotracheal suctioning

B

Use of cooling blanket

C

Incentive spirometry

D

Encouragement of coughing

Question 13 Explanation:

Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improves oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn’t be affected

Question 14

A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza?

A

Pneumonia

B

Pulmonary edema

C

Meningitis

D

Septicemia

Question 14 Explanation:

Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye’s syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren’t associated with influenza.

Question 15

Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

A

Urine output of 40 ml/hour

B

Dilated and reactive pupils

C

Heart rate of 100 beats/minute

D

Respiratory rate of 22 breaths/minute

Question 15 Explanation:

In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

Question 16

Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

A

Semiconsciousness

B

Delirium

C

Hyperventilation

D

Hypoxia

Question 16 Explanation:

depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

Question 17

The amount of air inspired and expired with each breath is called:

A

dead-space volume

B

tidal volume

C

residual volume.

D

vital capacity

Question 17 Explanation:

Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways

Question 18

A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

A

At least 2 hours after a meal

B

Immediately before a meal

C

When secretions have mobilized

D

When bronchospasms occur

Question 18 Explanation:

The nurse should perform chest physiotherapy at least 2 hours after a meal to reduce the risk of vomiting and aspiration. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn’t available) are a contraindication for postural drainage, another component of chest physiotherapy.

Question 19

A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client’s serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

Nurse Eve formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include:

A

eating more than three large meals a day.

B

eating a high-protein snack at bedtime

C

drinking more than 1,500 ml of fluid daily.

D

being overweight

Question 20 Explanation:

Conditions that increase oxygen demands include obesity, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals a day may cause fullness, making breathing uncomfortable and difficult; however, it doesn’t increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six a day).

Question 21

A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

A

Partial pressure of arterial oxygen (PaO2)

B

Bicarbonate (HCO3–)

C

pH

D

Partial pressure of arterial carbon dioxide (PaCO2)

Question 21 Explanation:

The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client’s ventilation status, not oxygenation.

Question 22

A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:

A

acute adrenocortical insufficiency.

B

hyperglycemia and glycosuria.

C

GI bleeding.

D

restlessness and seizures

Question 22 Explanation:

Administration of a corticosteroid such as prednisone suppresses the body’s natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.

Hypotension, hypothermia, and vasoconstriction may alter pulse oximetry values by reducing arterial blood flow. Likewise, movement of the finger to which the oximeter is applied may interfere with interpretation of SaO2. All of these conditions limit the usefulness of pulse oximetry. Fever, tachypnea, and tachycardia don’t affect pulse oximetry values directly.

Question 24

A male client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He’s placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

A

0.35

B

0.5

C

0.21

D

0.7

Question 24 Explanation:

An FO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air F IO 2 0.18 to 0.21.

Question 25

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86% and he’s still wheezing. The nurse should plan to administer:

A

propranolol (Inderal)

B

morphine

C

albuterol (Proventil).

D

alprazolam (Xanax).

Question 25 Explanation:

The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client’s greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It’s given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client’s breathing. Propranolol is contraindicated in a client who’s wheezing because it’s a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

A

Enforcing absolute bed rest

B

Enforcing absolute bed rest

C

Enforcing absolute bed rest

D

Restricting fluid intake to 1,000 ml/day

Question 27 Explanation:

Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client’s ability to maintain a patent airway, causing a high risk of infection from pooled secretions

Question 28

A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

A

Impaired gas exchange related to airflow obstruction

B

Risk for infection related to retained secretions

C

Activity intolerance related to fatigue

D

Anxiety related to actual threat to health status

Question 28 Explanation:

A patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis. The other options also may apply to this client but are less important

Question 29

For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?

A

Maintaining continuous bubbling in the water-seal chamber

B

Measuring and documenting the drainage in the collection chamber

C

Stripping the chest tube every hour

D

Keeping the collection chamber at chest level

Question 29 Explanation:

The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse should not strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

Question 30

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client’s medical history. Which condition is a predisposing factor for respiratory alkalosis?

A

Myasthenia gravis

B

Type 1 diabetes mellitus

C

Extreme anxiety

D

Narcotic overdose

Question 30 Explanation:

Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, and injury to the brain’s respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes mellitus may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul’s respirations) don’t cause excessive CO2 loss. Myasthenia gravis and narcotic overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

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Text Mode

Text Mode – Text version of the exam

1. The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?

Place the end of the chest tube in a container of sterile saline.

Apply an occlusive dressing and notify the physician.

Clamp the chest tube immediately.

Secure the chest tube with tape.

2. A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza?

Septicemia

Pneumonia

Meningitis

Pulmonary edema

3. A female client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

15 to 60 seconds.

5 to 20 minutes.

30 to 40 minutes.

45 to 60 minutes.

4. Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

6. A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:

hyperglycemia and glycosuria.

acute adrenocortical insufficiency.

GI bleeding.

restlessness and seizures.

7. A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

Activity intolerance related to fatigue

Anxiety related to actual threat to health status

Risk for infection related to retained secretions

Impaired gas exchange related to airflow obstruction

8. A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

Simple mask

Non-rebreather mask

Face tent

Nasal cannula

9. A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

11. The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

helping him communicate.

keeping his airway patent.

encouraging him to perform activities of daily living.

preventing him from developing an infection.

12. For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

Restricting fluid intake to 1,000 ml/day

Enforcing absolute bed rest

Teaching the client how to perform controlled coughing

Administering prescribed sedatives regularly and in large amounts

13. The amount of air inspired and expired with each breath is called:

tidal volume.

residual volume.

vital capacity.

dead-space volume.

14. A male client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He’s placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

0.21

0.35

0.5

0.7

15. Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?

A positive reaction indicates that the client has active tuberculosis (TB).

A positive reaction indicates that the client has been exposed to the disease.

A negative reaction always excludes the diagnosis of TB.

The PPD can be read within 12 hours after the injection.

16. Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute

Dilated and reactive pupils

Urine output of 40 ml/hour

Heart rate of 100 beats/minute

17. What is the normal pH range for arterial blood?

7 to 7.49

7.35 to 7.45

7.50 to 7.60

7.55 to 7.65

18. Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review?

Fluid intake for the last 24 hours

Baseline arterial blood gas (ABG) levels

Prior outcomes of weaning

Electrocardiogram (ECG) results

19. Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg?

Administer a prescribed decongestant.

Instruct the client to breathe into a paper bag.

Offer the client fluids frequently.

Administer prescribed supplemental oxygen.

20. A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

pH

Bicarbonate (HCO3–)

Partial pressure of arterial oxygen (PaO2)

Partial pressure of arterial carbon dioxide (PaCO2)

21. Nurse Julia is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which of the following interventions will most likely lower the client’s arterial blood oxygen saturation?

Endotracheal suctioning

Encouragement of coughing

Use of cooling blanket

Incentive spirometry

22. For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?

Measuring and documenting the drainage in the collection chamber

Maintaining continuous bubbling in the water-seal chamber

Keeping the collection chamber at chest level

Stripping the chest tube every hour

23. Nurse Eve formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include:

drinking more than 1,500 ml of fluid daily.

being overweight.

eating a high-protein snack at bedtime.

eating more than three large meals a day.

24. A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:

lips.

mucous membranes.

nail beds.

earlobes.

25. A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client’s serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

1 to 2 mcg/ml

2 to 5 mcg/ml

5 to 10 mcg/ml

10 to 20 mcg/ml

26. A male client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that:

vancomycin should be infused over 60 to 90 minutes in a large volume of fluid.

vancomycin may cause irreversible neutropenia.

vancomycin should be administered rapidly in a large volume of fluid.

vancomycin should be administered over 1 to 2 minutes as an I.V. bolus.

27. Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client’s medical history. Which condition is a predisposing factor for respiratory alkalosis?

Myasthenia gravis

Type 1 diabetes mellitus

Extreme anxiety

Narcotic overdose

28. At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86% and he’s still wheezing. The nurse should plan to administer:

30. Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

It helps prevent early airway collapse.

It increases inspiratory muscle strength

It decreases use of accessory breathing muscles.

It prolongs the inspiratory phase of respiration.

Answers and Rationales

Answer A. If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn’t clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.

Answer B. Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye’s syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren’t associated with influenza.

Answer B. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, and then gradually lengthen this interval according to the client’s respiratory status. A client who doesn’t require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn’t be long enough to reveal the client’s true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

Answer A. As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

Answer B. Administration of a corticosteroid such as prednisone suppresses the body’s natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.

Answer D. A patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis. The other options also may apply to this client but are less important.

Answer B. A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent and nasal cannula — deliver lower levels of FIO2.

Answer B. The nurse should perform chest physiotherapy at least 2 hours after a meal to reduce the risk of vomiting and aspiration. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn’t available) are a contraindication for postural drainage, another component of chest physiotherapy.

Answer D. Hypotension, hypothermia, and vasoconstriction may alter pulse oximetry values by reducing arterial blood flow. Likewise, movement of the finger to which the oximeter is applied may interfere with interpretation of SaO2. All of these conditions limit the usefulness of pulse oximetry. Fever, tachypnea, and tachycardia don’t affect pulse oximetry values directly.

Answer B. Maintaining a patent airway is the most basic and critical human need. All other interventions are important to the client’s well-being but not as important as having sufficient oxygen to breathe.

Answer C. Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client’s ability to maintain a patent airway, causing a high risk of infection from pooled secretions.

Answer A. Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.

Answer C. An FO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air F IO 2 0.18 to 0.21.

Answer B. A positive reaction means the client has been exposed to TB; it isn’t conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn’t exclude the presence of active disease.

Answer A. In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

Answer B. A pH less than 7.35 is indicative of acidosis; a pH above 7.45 indicates alkalosis.

Answer B. Before weaning a client from mechanical ventilation, it’s most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.

Answer B. The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options — such as administering a decongestant, offering fluids frequently, and administering supplemental oxygen — wouldn’t raise the lowered PaCO2 level.

Answer C. The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client’s ventilation status, not oxygenation.

Answer A. Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improves oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn’t be affected.

Answer A. The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse should not strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

Answer B. Conditions that increase oxygen demands include obesity, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals a day may cause fullness, making breathing uncomfortable and difficult; however, it doesn’t increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six a day).

Answer A. To avoid a hypotensive reaction from rapid I.V. administration, the nurse should infuse vancomycin slowly, over 60 to 90 minutes, in a large volume of fluid. Although neutropenia may occur in approximately 5% to 10% of clients receiving vancomycin, this adverse effect reverses rapidly when the drug is discontinued.

Answer C. Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, and injury to the brain’s respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes mellitus may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul’s respirations) don’t cause excessive CO2 loss. Myasthenia gravis and narcotic overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

Answer D. The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client’s greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It’s given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client’s breathing. Propranolol is contraindicated in a client who’s wheezing because it’s a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

Answer C. The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn’t affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler’s position and shouldn’t receive sedatives or other drugs that may further depress the respiratory center.

Answer A. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)